Case ReportMinimally Invasive Bilateral Lung Resections andCABG through 5 Ports

N. Asemota ,1,2M. J. Rouhani,2 L. Harling,2H. Raubenheimer,2A. C. De Souza,2 and E. Lim2

1The University of Nottingham, Queen’s Medical Centre, Derby Road, Nottingham NG7 2UH, UK2Department of Thoracic Surgery, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK

Correspondence should be addressed to N. Asemota; nasemota@doctors.org.uk

Received 6 January 2018; Accepted 27 May 2018; Published 13 December 2018

Academic Editor: Cheng-Yu Long

Copyright © 2018 N. Asemota et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work isproperly cited.

Minimal access surgery is increasingly popular to reduce postoperative morbidity and enhance recovery. We present a case of apatient who underwent bilateral minimally invasive thoracic and cardiac surgery. An 81-year-old woman was diagnosed withT1aN0M0 left upper lobe small-cell lung cancer and underwent single-port left video-assisted thoracoscopic surgery (VATS)upper lobectomy in 2016. She developed a contralateral right lower lobe nodule and underwent a single-port right VATS wedgeresection of the lower lobe nodule, subsequently confirmed as necrotising granulomatous inflammation with acid-fast bacilli,consistent with previous tuberculosis (TB) infection. On postoperative day 1, she had an episode of self-reverting ventriculartachycardia and bradycardia. Subsequent myocardial perfusion scan and coronary angiogram showed significant LV dysfunctionand severe coronary artery disease with a left main stem (LMS) lesion. After agreement at MDT, an Endo-ACAB (endoscopicatraumatic coronary artery bypass grafting) was performed, via 3 ports, with the left internal mammary artery anastomosed toleft anterior descending artery. She recovered well postoperatively and was discharged. Multiple sequential minimally invasiveprocedures are now routine and can be performed safely in patients with a complex combination of pathologies. In this case,bilateral single-port (anatomic and nonanatomic) lung resections were undertaken followed by coronary revascularisation with atotal of 5 minimal access ports.

1. Introduction

The use of minimally invasive surgery has become morewidespread over recent years across most surgical fields,likely due to its benefits in reducing length of stay dueto faster recovery times as well as causing less surgicaltrauma. Video-assisted thoracoscopic surgery (VATS) hasbeen firmly established in thoracic surgery, and recentdevelopments have led to increasingly more minimal tech-niques for cardiac surgery, including, but not limited to,Mini-Mitral and Endo-ACAB (endoscopic atraumatic cor-onary artery bypass grafting). In this case, we present arare circumstance of one patient having bilateral mini-mally invasive cardiac and thoracic surgery sequentially.

2. Case Report

An 80-year-old retired woman was referred to our car-diothoracic centre in February 2016 with an incidentalfinding of 1 cm lung nodule in the left midzone, afterhaving presented to her local hospital with chest dis-comfort. Her past medical history included previousright nephrectomy for a nonmalignant lesion of the ure-thra, a previous transient ischaemic attack, polymyalgiarheumatica, hypothyroidism, hypertension, and osteopo-rosis. Positron emission tomography-computed tomog-raphy (PET-CT) showed a T1a N0 M0 left upper lobecancer with small-cell lung carcinoma confirmed onCT-guided biopsy. The multidisciplinary team decision was

HindawiCase Reports in SurgeryVolume 2018, Article ID 9659232, 3 pageshttps://doi.org/10.1155/2018/9659232

for surgical management; therefore, she was admitted forelective lobectomy.

This was undertaken in March 2016 using a single-portVATS technique and included lymph node sampling.Sequential identification, dissection, and division of thepulmonary vessels and bronchi were performed as standard.The procedure was uncomplicated, and the patient wasdischarged 3 days later.

She then received adjuvant carboplatin/etoposide che-motherapy and was re-referred in December 2016 with acontralateral right lower lobe nodule found on surveillanceCT. The patient underwent single-port VATS wedge resec-tion of the nodule in February 2017, which was againuncomplicated. Interestingly, histopathological examinationrevealed the nodule to be an area of necrotising granuloma-tous inflammation with acid-fast bacilli, consistent with pasttuberculosis, rather than a metastasis.

On postoperative day 1, the patient had a self-resolvingepisode of ventricular tachycardia following by bradycardia,with chest tightness on minimal exertion. Troponin T wasperformed which was <20ng/L. She subsequently underwenta variety of cardiac investigations. Computed tomographycoronary angiogram (CTCA) was performed the followingday, which showed diffuse disease in all major epicardialvessels, with possible lesions in the left anterior descending(LAD) artery and right coronary artery (RCA), and a coro-nary calcification score of 1800. A 24-hour Holter investiga-tion revealed bradycardia throughout with rare ventricularectopics. A subsequent echocardiogram showed normal leftventricular size and function with an ejection fraction of60–65%, and a myocardial perfusion scan showed an overallischaemic burden of 7%. Finally, cardiac catheterisation onpostoperative day 8 revealed 85% tubular stenosis of thedistal left main stem (LMS) artery and minor irregularity inthe dominant right coronary artery (RCA).

The patient was symptomatically managed on theward, and the multidisciplinary team discussed the case.Bearing in mind the patient’s comorbidities, a decision wasmade for Endo-ACAB, rather than conventional cardiacartery bypass grafting (CABG) or percutaneous coronaryintervention (PCI), which took place 18 days after the initialthoracic surgery. 3 ports were utilised to harvest the leftinternal mammary artery (LIMA), and a submammaryincision was performed in the 5th intercostal space to enableanastomosis to the LAD. She developed no further complica-tions and was discharged 17 days later. She is awaitingcardiothoracic follow-up.

3. Discussion

This is an interesting case of a patient who underwent mini-mally invasive bilateral lung resections followed by coronaryartery bypass grafting, using 5 access ports.

This patient initially had 2 lung resections (ports 1 and 2)via VATS. VATS procedures for lung cancer were firstreported in 1991 [1, 2], and since then have becomecommonplace in thoracic surgery, with increases in use from2% in 1993 to 14% in 2011 of resection rates in the UK[3], with similar increasing trends across Europe [3]. This

is largely due to the increasing evidence of the benefits ofVATS for patient care, including reduced pain, reducedhospital stay, and lower risk of postoperative complica-tions [3, 4]. A large trial, such as the VIOLET (video-assisted thoracoscopic lobectomy versus conventional openlobectomy for lung cancer) trial, will enable furtherscrutiny to establish if there are any long-term clinicalbenefits of minimally invasive thoracic surgery over openthoracotomies [5].

The patient then underwent coronary revascularisation(ports 3–5), using the endo-ACAB procedure. This proce-dure, first reported in 1998 [6], involves using endoscopicequipment to harvest the LIMA and anastomose to theLAD, via port access [7]. Despite its early introduction, at asimilar time to that of minimally invasive thoracic surgery,the technical difficulties of surgical coronary revascularisa-tion using sole port-access surgery meant an initial shiftinstead towards the use of thoracotomy incisions, rather thanconventional sternotomies [8, 9]. However, there has been arecent trend towards endoscopic cardiac procedures as dem-onstrated in this case, with evidence of long-term success[10], alongside an increasing prevalence in the use of roboticsurgery [7, 8, 11].

In summary, this case highlights the increasing role ofminimally invasive techniques in both cardiac and thoracicsurgery, which should be considered whenmanaging patientswith a number of comorbidities.

Conflicts of Interest

The authors declare that there is no conflict of interestregarding the publication of this article.

Acknowledgments

The authors would like to acknowledgeMr. Richard Trimlett,Dr. Silviu Buderi, and Dr. Maria Elena Cufari for theirinvolvement in this case and their contributions towardsthe patient’s care.

References

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[2] G. Roviaro, C. Rebuffat, F. Varoli, C. Vergani, C. Mariani, andM. Maciocco, “Videoendoscopic pulmonary lobectomy forcancer,” Surgical Laparoscopy & Endoscopy, vol. 2, no. 3,pp. 244–247, 1992.

[3] S. Begum, H. J. Hansen, and K. Papagiannopoulos, “VATSanatomic lung resections—the European experience,” Jour-nal of Thoracic Disease, vol. 6, Supplement 2, pp. 203–210,2014.

[4] S. P. Luh and H. P. Liu, “Video-assisted thoracic surgery―thepast, present status and the future,” Journal of ZhejiangUniversity Science B, vol. 7, no. 2, pp. 118–128, 2006.

[5] E. Lim, T. Brush, and C. Rogers, “189 video assisted thoraco-scopic lobectomy versus conventional open lobectomy forlung cancer, a multi-centre randomised controlled trial with

2 Case Reports in Surgery

an internal pilot: the VIOLET study,” Lung Cancer, vol. 91,pp. S68–S69, 2016.

[6] F. G. Duhaylongsod, “Minimally invasive cardiac surgerydefined,” Archives of Surgery, vol. 135, no. 3, pp. 296–301,2000.

[7] W. G. Semere, T. M. Edwards, D. Boyd et al., “The world wideweb and robotic heart surgery,” The Heart Surgery Forum,vol. 6, no. 6, pp. E111–E119, 2003.

[8] M. J. Mack, “Minimally invasive and robotic surgery,” Journalof the American Medical Association, vol. 285, no. 5, pp. 568–572, 2001.

[9] J. T. McGinn, S. Usman, H. Lapierre, V. R. Pothula, T. G.Mesana, and M. Ruel, “Minimally invasive coronary arterybypass grafting: dual-center experience in 450 consecutivepatients,” Circulation, vol. 120, no. 11, Supplement 1,pp. S78–S84, 2009.

[10] T. A. Vassiliades Jr, V. S. Reddy, J. D. Puskas, and R. A.Guyton, “Long-term results of the endoscopic atraumaticcoronary artery bypass,” The Annals of Thoracic Surgery,vol. 83, no. 3, pp. 979–985, 2007.

[11] A. Iribarne, R. Easterwood, E. Y. H. Chan et al., “The goldenage of minimally invasive cardiothoracic surgery: current andfuture perspectives,” Future Cardiology, vol. 7, no. 3,pp. 333–346, 2011.

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